2.0 Analysis 2.1 Cause of the Fire The fire started in the engine-room, in the area in which the starboard generator and the boiler were located, but there was no conclusive evidence which would suggest that one of these two pieces of machinery may have been the cause of the fire. The electrical interference heard on the radio might suggest a malfunction of the generator's electrical components, and the explosion could be symptomatic of a problem with the furnace or a problem in the crankcase of the generator. However, sparking or a loose connection in any electrical circuit could have caused the electrical interference. The evidence was that the smoke could be smelled, and the fire had probably therefore started, before the explosion occurred. There was no other evidence linking the start of the fire to either the generator or the boiler; the precise cause of the fire was thus not determined. 2.2 Fighting the Fire Fighting a shipboard fire by introducing a smothering medium into a compartment relies on efficient exclusion of oxygen from the compartment. On the JUDITH SUZANNE, this was not done. The crew members' attempt to cut off the supply of air to the engine-room by using their shucking aprons to block the ventilation system would not have been as effective as closing the ventilator baffles. Furthermore, after the CO2 had been injected into the machinery space, insufficient time was allowed before the door was opened to check on the results. The fire, which had apparently been contained, was permitted a fresh supply of oxygen, allowing it to intensify until it was out of control. It cannot be stated with certainty that the fire would have been extinguished if the crew had waited longer, but the door was opened without allowing enough time for the fire to die out. When the fire flared up again, the only means left to the crew to fight the fire was the four portable fire extinguishers which were located outside the engine-room. Without a breathing apparatus, which the vessel did not carry, the crew could not enter the CO2 and smoke-filled machinery space, and the only fire pump that could have been used outside the engine-room was stored in the engine-room. 2.3 Crew Training Only three of the crew members on the JUDITH SUZANNE had taken a MED course and received the instruction on fighting shipboard fires provided by such a course. The practice of not holding regular emergency drills on the JUDITH SUZANNE meant that there was only a limited possibility of the other crew members acquiring any of the skills required to successfully fight a fire on board a ship. 3.0 Conclusions 3.1 Findings The outbreak of the fire was not noticed because the engine-room was not manned at the time. The vessel was not fitted with a fire- or smoke-detection and alarm system. The fire-fighting potential of the CO2 smothering system was offset by oxygen being reintroduced into the engine-room when the door was opened prematurely. The fuel supply to the main engine was not shut off promptly. The baffles in the engine-room ventilators were not closed. The vessel was not fitted with an emergency generator. The one pump that could have been used outside the engine-room was stored in the engine-room. Of the vessel's fire-fighting equipment, only four portable extinguishers were located outside the engine-room. The vessel did not carry a breathing apparatus. The crew had not been trained or drilled in shipboard fire-fighting techniques. The Emergency Position Indicating Radio Beacons (EPIRBs) were not utilized. When the main electrical power failed, the vessel's radiotelephone range for distress messages was limited. 3.2 Causes The JUDITH SUZANNE was lost as a result of an engine-room fire of undetermined origin. The fire was not detected promptly because the compartment was not continually manned and the vessel was not fitted with a fire alarm system. The fire spread and intensified beyond the vessel's fire-fighting capabilities. 4.0 Safety Action 4.1 Action Taken It was evident that the crew's lack of formal training in Marine Emergency Duties (MED), such as fire-fighting techniques, contributed to the severity of this occurrence. In its report on a 1991 occurrence (TSB report No. M91W1075), the Board expressed concern over inadequately trained personnel on fishing vessels contributing to the frequency and severity of marine occurrences, whether they are on watch, handling a catch, or operating emergency and safety systems. Further, as a result of its investigation into the sinking of the fishing vessel STRAITS PRIDE II in December 1990, the Board recommended that: The Department of Transport ensure that personnel who regularly crew closed- construction fishing vessels receive formal training in life-saving equipment and survival techniques. A proposed amendment to the Canada Shipping Act (CSA) is now being developed that would require non-certificated personnel to undergo recommended training. 4.2 Safety Concern 4.2.1 Fires on Fishing Vessels TSB records indicate that, between 1989 and 1993, there was, on average, 62 fires a year on board Canadian fishing vessels; over 50 per cent of these fires resulted in the loss of the vessel. During the same period, an average of 17 fires occurred in engine-rooms annually4. According to the Japanese classification society's (Nippon Kaiji Kyokai (NK)) Study Committee on the Prevention of Engine Room Fires5, the most common hazard leading to engine-room fires is fuel spray from damaged pipes. This is supported by the data from Canadian occurrences involving fishing vessels. The major causes of engine-room fires reported in Canada include fuel or hydraulic fluid from broken pipes and fittings spraying on hot engine parts; faulty electrical systems; and uninsulated exhausts in contact with flammable materials. Moreover, the 1987 Canadian Coast Guard (CCG) study into Fishing Vessel Safety6 indicated that, for the period from 1982 to 1986 inclusive, the major reported causes of vessel losses were fire and explosion, which accounted for 381 occurrences. The study cited improperly installed and maintained heaters; incorrect fuse ratings for electrical circuits; improperly secured and/or fractured fuel lines; oil or gas in bilges; and improperly installed propane systems as the major reason for the fires. Notwithstanding that the CCG has long recognized the hazards associated with fire on board fishing vessels and has issued several Ship Safety Bulletins on the subject (in 1984, 1985, and 1989), there continues to be a significant number of fires in the engine-room of fishing vessels. Given the aforementioned Canadian statistics and as a result of recent fires on large fishing vessels (such as the JUDITH SUZANNE and the 488 gross-ton fishing vessel RALI II (TSB Report No. M94M0020)), the Board is concerned about the extent to which engine-room fires on board vessels continue to cause significant losses in the Canadian fishing fleet. Hence, the Board will assess these types of occurrences with a view to determining the need for further safety action.